Basic Information
Provider Information | |||||||||
NPI: | 1124030424 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PIKE COUNTY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PCMH CLINIC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2305 GEORGIA ST | ||||||||
Address2: |   | ||||||||
City: | LOUISIANA | ||||||||
State: | MO | ||||||||
PostalCode: | 633532559 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5737544584 | ||||||||
FaxNumber: | 5737545280 | ||||||||
Practice Location | |||||||||
Address1: | 1015 W ADAMS ST | ||||||||
Address2: |   | ||||||||
City: | BOWLING GREEN | ||||||||
State: | MO | ||||||||
PostalCode: | 633341974 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5733245300 | ||||||||
FaxNumber: | 5733246059 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/13/2006 | ||||||||
LastUpdateDate: | 04/05/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SELLE | ||||||||
AuthorizedOfficialFirstName: | JUSTIN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5737545531 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | CK7206 | 01 | MO | RAILROAD MEDICARE PIN | OTHER | 502663305 | 01 | MO | MEDICARE/MEDICAID PROF CROSSOVER 1500 | OTHER | 598209203 | 05 | MO |   | MEDICAID |